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Objective: Patients with psychiatric disorders are at risk of experiencing suboptimal cancer diagnostics and treatment. This study investigates how this patient group perceives the cancer diagnostic process in general practice., Design: Cross-sectional study using questionnaire and register data., Setting: General practice in Denmark., Subjects: Patients diagnosed with cancer in late 2016 completed a questionnaire about their experiences with their general practitioner (GP) in the cancer diagnostic process ( n  = 3411). Information on pre-existing psychiatric disorders was obtained from register data on psychiatric hospital contacts and primary care treated psychiatric disorders through psychotropic medications. Logistic regression was used to analyse the association between psychiatric disorders and the patients' experiences., Main Outcome Measures: Patients' experiences, including cancer worry, feeling being taken seriously, and the perceived time between booking an appointment and the first GP consultation.[Box: see text]., Results: A total of 13% of patients had an indication of a psychiatric disorder. This group more often perceived the time interval as too short between the first booking of a consultation and the first GP consultation. Patients with primary care treated psychiatric disorders were more likely to worry about cancer at the first presentation and to share this concern with their GP compared with patients without psychiatric disorders. We observed no statistically significant association between patients with psychiatric disorders and perceiving the waiting time to referral from general practice, being taken seriously, trust in the GP's abilities, and the patients' knowledge of the process following the GP referral., Conclusion: The patients' experiences with the cancer diagnostic process in general practice did not vary largely between patients with and without psychiatric disorders. Worrying about cancer may be a particular concern for patients with primary care treated psychiatric disorders.

Older cancer patients are more often than younger diagnosed via an unplanned hospital admission which may negatively influence the prognosis. An increasing number of cancers is expected due to ageing of populations, and these phenomena are likely to result in an increase in older cancer patients with multiple complications, extended hospital stays, and reduced quality of life and survival. In this review, we present recent data about routes to cancer diagnosis for older vs younger patients to emphasize that diagnostic pathways need improvements to avoid an increase in unplanned hospital admissions due to cancer., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Unplanned presentation in the cancer pathway is more common in patients with psychiatric disorders than in patients without. More knowledge about the risk factors for unplanned presentation could help target interventions to ensure earlier diagnosis of cancer in patients with psychiatric disorders. This study aims to estimate the association between patient characteristics (social characteristics and coexisting physical morbidity) and cancer diagnosis following unplanned presentation among cancer patients with psychiatric disorders. We conducted a population-based register study including patients diagnosed with cancer in 2014-2018 and also registered with at least one psychiatric disorder in the included Danish registers (n = 26,005). We used logistic regression to assess patient characteristics associated with an unplanned presentation. Almost one in four symptomatic patients (23.6 %) with pre-existing psychiatric disorders presented unplanned in the cancer trajectory. Unplanned presentation was most common for severe psychiatric disorders, e.g. organic disorders and schizophrenia. Old age, male sex, living alone, low education, physical comorbidity, and non-attendance in primary care were associated with increased odds of unplanned presentation. In conclusion, several characteristics of patients with pre-existing psychiatric disorders were associated with unplanned presentation in the cancer trajectory; for some groups more than 40 % had an unplanned presentation. This information could be used to design targeted interventions for patients with pre-existing psychiatric disorders to ensure earlier diagnosis of cancer in this population., Competing Interests: Conflict of interest None. None of the authors declares any conflicts of interest., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The time interval from first symptom and sign until a cancer diagnosis significantly affects the prognosis. Therefore, recognising and acting on signs of cancer, such as anaemia, is essential. Evidence is sparse on the overall risk of cancer and the risk of specific cancer types in persons with new-onset anaemia detected in an unselected general practice population. We aimed to assess the risk of cancer in persons with new-onset anaemia detected in general practice, both overall and for selected cancer types., Methods: This observational population-based cohort study used individually linked electronic data from laboratory information systems and nationwide healthcare registries in Denmark. We included persons aged 40-90 years without a prior history of cancer and with new-onset anaemia (no anaemia during the previous 15 months) detected in general practice in 2014-2018. We measured the incidence proportion and standardised incidence ratios of a new cancer diagnosis (all cancers except for non-melanoma skin cancers) during 12 months follow-up., Results: A total of 48,925 persons (median [interquartile interval] age, 69 [55-78] years; 55.5% men) were included in the study. In total, 7.9% (95% confidence interval (CI): 7.6 to 8.2) of men and 5.2% (CI: 4.9 to 5.5) of women were diagnosed with cancer during 12 months. Across selected anaemia types, the highest cancer incidence proportion was seen in women with 'anaemia of inflammation' (15.3%, CI: 13.1 to 17.5) (ferritin > 100 ng/mL and increased C-reactive protein (CRP)) and in men with 'combined inflammatory iron deficiency anaemia' (19.3%, CI: 14.5 to 24.1) (ferritin < 100 ng/mL and increased CRP). For these two anaemia types, the cancer incidence across cancer types was 10- to 30-fold higher compared to the general population., Conclusions: Persons with new-onset anaemia detected in general practice have a high cancer risk; and markedly high for 'combined inflammatory iron deficiency anaemia' and 'anaemia of inflammation'. Anaemia is a sign of cancer that calls for increased awareness and action. There is a need for research on how to improve the initial pathway for new-onset anaemia in general practice., (© 2022. The Author(s).)

Objective: Timely diagnosis of cancer is important for prognosis. Patients' health literacy (HL) may impact differences of diagnostic delays. Thus, we aim to explore the association between HL and diagnostic intervals in cancer., Methods: Questionnaire data were obtained from patients with cancer diagnosed in 2016 and their general practitioner (n = 3890). The primary care interval (PCI) and the diagnostic interval (DI) were calculated using dates from national registries and questionnaires. A long PCI and DI were defined as ≥75th percentile. HL was assessed using scales from the Health Literacy Questionnaire: engaging with healthcare providers (scale 6:Engagement, n = 3008), navigating in healthcare (scale 7:Navigation, n = 2827) and understanding health information (scale 9:Knowledge, n = 3002). Low HL was defined as a score ≤3., Results: Low HL was reported by 12.2% (Engagement), 27.0% (Navigation) and 9.3% (Knowledge) of the patients and associated with a long PCI after adjustment of socio-economic factors: Engagement (prevalence rate ratio [PRR] 1.27 [95% CI 1.01-1.60]), Navigation (PRR 1.41 [95% CI 1.10-1.80]) and Knowledge (PRR 1.32 [95% CI 1.03-1.68]). No association was found between HL and DI., Conclusion: HL may interfere with the diagnostic processes in general practice. Efforts to manage low HL include GPs' awareness of patients' ability to explain and respond to bodily changes and use of corresponding safety-netting strategies., (© 2021 John Wiley & Sons Ltd.)

Background: Anaemia is associated with adverse outcomes, including increased morbidity and all-cause mortality. Diagnostic workup of patients with anaemia is essential to detect underlying disease, especially undiagnosed malignancy., Objective: To describe the cancer-relevant diagnostic workup in patients with new-onset anaemia detected in general practice. An additional aim was to analyse associations between patient characteristics and the diagnostic workup., Design: Observational population-based cohort study using electronic laboratory and register data., Setting: Danish general practice., Subjects: Patients aged 40-90 years with new-onset anaemia (no anaemia in the preceding 15 months) detected in general practice. Patients were identified in Danish laboratory information systems and nationwide registries in 2014-2018., Main Outcome Measures: We measured the proportion of patients receiving predefined diagnostic investigations, that is, cancer patient pathway, colonoscopy, gastroscopy, computerised tomography (CT) scan, faecal test for haemoglobin, and bone marrow examination within three months of the anaemia index date., Results: We included 59,993 patients, and around half of the patients with 'iron deficiency anaemia', 'anaemia of inflammation', or 'combined inflammatory iron deficiency anaemia' had no cancer-relevant diagnostic investigations performed. Patients aged 60-79 years and patients with severe anaemia were more likely to have investigations performed, while patients with comorbidity were less likely to have investigations performed., Conclusion: Around half of the patients with anaemia subtypes that may indicate underlying cancer had no cancer-relevant diagnostic investigations performed. This may represent missed diagnostic opportunities. Future interventions are needed to improve the diagnostic workup of cancer in patients with anaemia, for example, laboratory alert systems and clinical decision support.KEY POINTSThe general practitioners are often the first to detect anaemia and its underlying disease (e.g. undiagnosed malignancy).Large-scale studies are needed on the diagnostic workup of patients with anaemia in general practice in relation to an underlying malignancy.This study shows that the majority of patients with anaemia had no cancer-relevant diagnostic investigations performed, which may cause diagnostic delay.Interventions seems needed to improve the diagnostic workup of cancer in these patients to ensure timely diagnosis.

Objective: To explore how cancer could be diagnosed in a more timely way., Design: Grounded theory analysis of primary care physicians' free text survey responses to: 'How do you think the speed of diagnosis of cancer in primary care could be improved?'. Secondary analysis of primary care physician interviews, survey responses, literature., Setting: Primary care in 20 European Örenäs Research Group countries., Subjects: Primary care physicians: 1352 survey respondents (2013-2016), 20 Spanish and 7 Swedish interviewees (2015-2019)., Main Outcome Measures: Conceptual explanation of how to improve timeliness of cancer diagnosis., Results: Pluralistic task shifting is a grounded theory of a composite strategy. It includes task sharing - among nurses, physicians, nurse assistants, secretaries, and patients - and changing tasks with cancer screening when appropriate or cancer fast-tracks to accelerate cancer case finding. A pluralistic dialogue culture of comprehensive collaboration and task redistribution is required for effective pluralistic task shifting. Pluralistic task shifting relies on cognitive task shifting, which includes learning more about slow analytic reasoning and fast automatic thinking initiated by pattern recognition; and digital task shifting, which by use of eHealth and telemedicine bridges time and place and improves power symmetry between patients, caregivers, and clinicians. Financial task shifting that involves cost tracking followed by reallocation of funds is necessary for the restructuring and retraining required for successful pluralistic task shifting. A timely diagnosis reduces expensive investigations and waiting times. Also, late-stage cancers are costlier to treat than early-stage cancers. Timing is central to cancer diagnosis: not too early to avoid overdiagnosis, and never too late., Conclusions: We present pluralistic task shifting as a conceptual summary of strategies needed to optimise the timeliness of cancer diagnosis.Key pointsCancer diagnosis is under-researched in primary care, especially theoretically. Thus, inspired by classic grounded theory, we analysed and conceptualised the field: Pluralistic task shifting is a conceptual explanation of how the timeliness of cancer diagnosis could be improved, with data derived mostly from primary care physicians.This includes task sharing and changing tasks including screening and cancer fast-tracks to accelerate cancer case finding, and requires cognitive task shifting emphasising learning, and digital task shifting involving the use of eHealth and telemedicine. Financial task shifting with cost tracking and reallocation of funds is eventually necessary for successful pluralistic task shifting to happen.

Background: The prognosis of cancer is related to how the cancer is identified, and where in the healthcare system the patient presents, i.e. routes to diagnosis (RtD). We aimed to describe the RtD for patients diagnosed with cancer in Denmark by using routinely collected register-based data and to investigate the association between RtD and prognosis measured as one-year all-cause mortality., Methods: We conducted a population-based national cohort study by linking routinely collected Danish registry data. We categorised each patient into one of eight specified RtD based on an algorithm using a stepwise logic decision process. We described the proportions of patients with cancer diagnosed by different RtD. We examined associations between RtD and one-year all-cause mortality using logistic regression models adjusting for sex, age, cancer type, year of diagnosis, region of residence, and comorbidity., Results: We included 144,635 cancers diagnosed in 139,023 patients in 2014-2017. The most common RtD were cancer patient pathway from primary care (45.9 %), cancer patient pathway from secondary care (20.0 %), unplanned hospital admission (15.8 %), and population-based screening (7.5 %). The one-year mortality ranged from 1.4 % in screened patients to 53.0 % in patients diagnosed through unplanned hospital admission. Patients with an unplanned admission were more likely to die within the first year after diagnosis (OR = 3.38 (95 %CI: 3.24-3.52)) compared to patients diagnosed through the cancer patient pathway from primary care., Conclusion: The majority of cancer patients were diagnosed through a cancer patient pathway. The RtD were associated with the prognosis, and the prognosis was worst in patients diagnosed through unplanned admission. The study suggests that linking routinely collected registry data could enable a national framework for RtD, which could serve to identify variations across patient-, health-, and system-related and healthcare factors. This information could be used in future research investigating markers for monitoring purposes., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: General practitioners (GPs) have a key role in the diagnosis of cancer. It is crucial to identify factors influencing the decision to refer for suspected cancer. The aim of this study was to investigate the alignment between the patient's cancer worry and the GP's suspicion of cancer in the first clinical encounter and the association with the time interval from the first symptom presentation until the first referral to specialist care, i.e. the primary care interval (PCI)., Method: The study was performed as a cross-sectional study using survey data on patients diagnosed with incident cancer in 2010 or 2016 and their GPs in Denmark. We defined four alignment groups: 1) patient worry and GP suspicion, 2)  GP suspicion only, 3) patient worry only, and 4) none of the two. A long PCI was defined as an interval longer than the 75th percentile., Results: Among the 3333 included patients, both patient worry and GP suspicion was seen in 39.5%, only GP suspicion was seen in 28.2%, only patient worry was seen in 13.6%, and neither patient worry nor GP suspicion was seen in 18.2%. The highest likelihood of long PCI was observed in group 4 (group 4 vs. group 1: PPR 3.99 (95% CI 3.34-4.75)), mostly pronounced for easy-to-diagnose cancer types., Conclusion: Misalignment between the patient's worry and the GP's suspicion was common at the first cancer-related encounter. Importance should be given to the patient interview, due to a potential delayed GP referral among patients diagnosed with "easy-to-diagnose" cancer types presenting with unspecific symptoms.

Objective: A general practitioner's (GP's) suspicion of cancer is important to ensure early diagnosis of cancer. This study aimed to investigate the association between patients' cancer worry and GP's suspicion of cancer or serious illness., Methods: This population-based study was based on Danish register and questionnaire data from 4,175 incident cancer patients diagnosed in 2010 or 2016 and their GPs. The association between the patient's worry about cancer and their GP's suspicion of cancer or serious illness was estimated by generalised linear models with log link for the Poisson family and presented in prevalence rate ratios (PRR)., Results: For 6 in 10 of the cases, the first consultation was categorised by absence of both or either patient worry or GP suspicion. When patients worried about cancer, the GPs were more likely to suspect cancer or serious illness in patients (PRR=1.26, (95%CI: 1.20-1.34)). For all levels of patient worry and most pronounced among very worried patients, GPs less often suspected cancer or serious illness in patients who presented with an ´intermediate´ or ´hard´ to diagnose cancer., Conclusion: GPs were more likely to suspect cancer or serious illness in patients who worried about cancer at the first presentation., (© 2021 John Wiley & Sons Ltd.)

Objectives: Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different healthcare systems influence primary care practitioners' (PCPs) referral decisions in patients who could have cancer.This study aimed to explore PCPs' diagnostic actions (whether or not they perform a key diagnostic test and/or refer to a specialist) in patients with symptoms that could be due to cancer and how they vary across European countries., Design: A primary care survey. PCPs were given vignettes describing patients with symptoms that could indicate cancer and asked how they would manage these patients. The likelihood of taking immediate diagnostic action (a diagnostic test and/or referral) in the different participating countries was analysed. Comparisons between the likelihood of taking immediate diagnostic action and physician characteristics were calculated., Setting: Centres in 20 European countries with widely varying cancer survival rates., Participants: A total of 2086 PCPs answered the survey question, with a median of 72 PCPs per country., Results: PCPs' likelihood of immediate diagnostic action at the first consultation varied from 50% to 82% between countries. PCPs who were more experienced were more likely to take immediate diagnostic action than their peers., Conclusion: When given vignettes of patients with a low but significant possibility of cancer, more than half of PCPs across Europe would take diagnostic action, most often by ordering diagnostic tests. However, there are substantial between-country variations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Research indicate that when general practitioners (GPs) refer their patients for specialist care, the patient often has long distance. This study had a twofold aim: in accordance to the GP's suspicion of cancer, we investigated the association between: 1) cancer patient's travel distance to the first specialised diagnostic facility and the GP's diagnostic strategy and 2) cancer patient's travel distance to the first specialised diagnostic facility and satisfaction with the waiting time and the availability of diagnostic investigations., Method: This combined questionnaire- and registry-based study included incident cancer patients diagnosed in the last 6 months of 2016 where the GP had been involved in the diagnostic process of the patients prior to their diagnosis of cancer (n = 3455). The patient's travel distance to the first specialised diagnostic facility was calculated by ArcGIS Network Analyst. The diagnostic strategy, cancer suspicion and the GP's satisfaction with the waiting times and the available investigations were assessed from GP questionnaires., Results: When the GP did not suspect cancer or serious illness, an insignificant tendency was seen that longer travel distance to the first specialised diagnostic facility increased the likelihood of the GP using 'wait-and-see' approach and 'medical treatment' as diagnostic strategies. The GPs of patients with travel distance longer than 49 km to the first specialised diagnostic facility were more likely to report dissatisfaction with the waiting time for requested diagnostic investigations (PR: 1.98, 95% CI: 1.20-3.28)., Conclusion: A insignificant tendency to use 'wait-and-see' and 'medical treatment' were seen among GPs of patients with long travel distance to the first diagnostic facility when the GP did not suspect cancer or serious illness. Long distance was associated with higher probability of GP dissatisfaction with the waiting time for diagnostic investigations.

Background: Rural-dwellers have poorer cancer outcomes than urban counterparts, for reasons which are unclear. At healthcare institution level, poorer access to investigations and different clinical decision-making by rural primary healthcare practitioners (PCPs) could be important., Aim: To compare access to investigations, attitudes to cancer diagnosis and clinical decision-making between rural and urban PCPs., Setting: A vignette-based cross-sectional survey of rural and urban PCPs in 20 European countries., Methods: Data on PCPs' decision-making and attitudes to cancer diagnosis were based on clinical scenarios. Comparisons were made using tests of proportion, univariable and multivariable binary logistic regression., Results: Of the 1779 PCPs completing the survey 541 30.4 %) practiced rurally. Rural PCPs had significantly less direct access to all investigative modalities: ultrasound; endoscopy; x-ray and advanced screening (all p < 0.001). Rural PCPs were as likely as urban PCPs to take diagnostic action (investigation and/or referral) at the index consultation in all four clinical vignettes ((OR, 95 % CI) for lung: 0.90, 0.72-1.12; ovarian: 0.95, 0.75-1.19; breast: 0.87, 0.69-1.09; colorectal: 0.98, 0.75-1.30). Rural PCPs were less likely to refer to a specialist at the index consultation for ovarian cancer (OR 0.71 95 % CI 0.51-0.99). Rural PCPs were significantly more likely to report that their patients faced barriers to accessing specialist care, but practitioners did not report greater difficulties making specialist referral than their urban counterparts CONCLUSIONS: European rural PCPs report poorer access to investigations but are at least as likely as urban PCPs to investigate or refer patients that might have cancer at the index consultation., Competing Interests: Declaration of Competing Interest PM, WK, RA, ME, ES, DP, HT, PV, DM and MH have no competing interests to declare., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The routes to diagnosis and the time intervals along the diagnostic pathway affect cancer outcomes. Some data on routes to diagnosis and milestone dates can be extracted from registries or databases. When this data is incomplete, inaccurate or non-existing, other data sources are needed. This study investigates the agreement between multiple data sources on routes to diagnosis and milestone dates of cancer pathway., Methods: Information on routes to diagnosis and milestone dates were compared across four data sources (cancer patients, general practitioners, cancer specialists and registries) for breast, colorectal, lung and ovarian cancers across the UK, Scandinavia, Canada and Australia. Agreement on routes to diagnosis and milestone dates was assessed by Kappa and AC1 coefficients and Lin's concordance correlation coefficient (CCC)., Results: 4502 patients were included in the analysis of routes to diagnosis. The agreement was almost perfect (kappa = 0.15-0.88, AC1 = 0.86-0.91) for breast cancer, substantial to almost perfect (kappa = 0.07-0.86, AC1 = 0.74-0.93) for colorectal and ovarian cancers, and substantial (kappa = 0.09-0.11, AC1 = 0.65-0.74) for lung cancer. 2287 patients were included in the analysis of milestone dates. The agreement was adequate for all cancer types (CCC = 0.88-0.99); highest agreement was seen for date of diagnosis (CCC = 0.94-0.99)., Conclusion: We found a reasonable agreement between patient/physician questionnaires and registry data for routes to diagnosis and milestone dates. The agreement on routes to diagnosis was generally higher for breast cancer than for colorectal, ovarian and lung cancers. Lower agreement was seen on date of first presentation to primary care and date of treatment initiation compared to date of diagnosis., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Specialisation and centralisation in healthcare systems increase patients' travel distance to cancer-diagnostic facilities but the impact of distance on tumour stage remains unclear. This study aimed to study the travel distance to cancer patient's GP and to the hospital of diagnosis and the association with tumour stage for 12 cancer types. A cohort study was conducted including cancer patients in Denmark diagnosed between 2005 and 2016 with rectum, malignant melanoma, breast, testis, oesophageal, colon, cervix, prostate, stomach, pancreatic, lung and ovary cancer (n = 256,663). Distance to each patient's GP and to the hospital of diagnosis were calculated using ArcGIS, Network Analyst. The results showed that for most easy-to-diagnose cancer types (rectum cancer, malignant melanoma, testis cancer) and cervix cancer, increasing travel distance to the hospital of diagnosis increased the odds of advanced disease at diagnosis. Contrary, increasing travel distance to the hospital was associated with decreased odds of being diagnosed with advanced disease stage among hard-to-diagnose cancer types (stomach, pancreatic, lung and ovarian cancer), and prostate cancer. Distance to the GP was overall not associated with tumour stage. The underlying mechanisms for these findings are multifaceted and might reflect differences in presentation, symptomologies and investigations used for diagnosis across cancer types., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: This study aimed to explore individual and structural factors in patients with cancer and their potential association with customary non-attendance in general practice., Materials and Methods: We conducted a population-based cross-sectional study of all patients aged 50-89 years who were diagnosed with an incident cancer in 2009-2013 in Denmark. We investigated associations between being a customary non-attender (defined as having no consultations in general practice in the 19-36 months before diagnosis) and selected patient-related factors (demography, socioeconomic status), health-related factors (multimorbidity) and structural factors (urbanisation degree, list size of general practice and use of out-of-hours services) using logistic regression., Results: A total of 123,943 cancer patients were included; 11,567 (9.3%) of these were non-attenders. Non-attendance was associated with being more than 70 years of age, being single, having short or long education and being financially affluent. Non-attendance was rarely seen in cancer patients with (multi)morbidity, in individuals living in an area with 2,000-99,999 inhabitants and in individuals having contact with the out-of-hours services., Conclusion: Specific groups of cancer patients were more often customary non-attenders in general practice. General practice may need to reach out more directly to these patients to ensure more timely cancer diagnosis., (© 2019 John Wiley & Sons Ltd.)

Background: National European cancer survival rates vary widely. Prolonged diagnostic intervals are thought to be a key factor in explaining these variations. Primary care practitioners (PCPs) frequently play a crucial role during initial cancer diagnosis; their knowledge could be used to improve the planning of more effective approaches to earlier cancer diagnosis., Objectives: This study sought the views of PCPs from across Europe on how they thought the timeliness of cancer diagnosis could be improved., Design: In an online survey, a final open-ended question asked PCPs how they thought the speed of diagnosis of cancer in primary care could be improved. Thematic analysis was used to analyse the data., Setting: A primary care study, with participating centres in 20 European countries., Participants: A total of 1352 PCPs answered the final survey question, with a median of 48 per country., Results: The main themes identified were: patient-related factors, including health education; care provider-related factors, including continuing medical education; improving communication and interprofessional partnership, particularly between primary and secondary care; factors relating to health system organisation and policies, including improving access to healthcare; easier primary care access to diagnostic tests; and use of information technology. Re-allocation of funding to support timely diagnosis was seen as an issue affecting all of these., Conclusions: To achieve more timely cancer diagnosis, health systems need to facilitate earlier patient presentation through education and better access to care, have well-educated clinicians with good access to investigations and better information technology, and adequate primary care cancer diagnostic pathway funding., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate the relationship between tumour stage at diagnosis and selected components of primary and secondary care in the diagnostic interval for breast, colorectal, lung and ovarian cancers., Methods: Observational study based on data from 6,162 newly diagnosed symptomatic cancer patients from Module 4 of the International Cancer Benchmarking Partnership. We analysed the odds of advanced stage of cancer as a flexible function of the length of primary care interval (days from first presentation to referral) and secondary care interval (days from referral to diagnosis), respectively, using logistic regression with restricted cubic splines., Results: The association between time intervals and stage was similar for each type of cancer. A statistically significant U-shaped association was seen between the secondary care interval and the diagnosis of advanced rather than localised cancer, odds decreasing from the first day onwards and increasing around three and a half months. A different pattern was seen for the primary care interval, flat trends for colorectal and lung cancers and a slightly curved association for ovarian cancer, although not statistically significant., Conclusion: The results confirm previous findings that some cancers may progress even within the relatively short time frame of regulated diagnostic intervals. The study supports the current emphasis on expediting symptomatic diagnosis of cancer., (© 2019 John Wiley & Sons Ltd.)

Objective: Specialised follow-up care after cancer treatment is changing towards increased involvement of general practice. To ensure timely detection of new cancer events, knowledge is warranted on the timing of cancer recurrence (CR) and second primary cancer (SPC), including risk factors for CR., Methods: This population-based register study included 67,092 patients diagnosed with malignant melanoma, bladder, lung, ovarian, endometrial, colorectal and breast cancer in Denmark in 2008-2016. The time from primary cancer to CR or SPC and risk factors for prolonged time to CR were analysed and stratified on sex and primary cancer type., Results: Cancer recurrence proportions ranged from 6% to 35%. The risk of CR increased profoundly within the first 3 years and then levelled off, except for breast cancer. A total of 3%-6% of patients had SPC, with monotonously increasing cumulative incidence proportions. Besides primary tumour characteristics, lower educational level, living alone and comorbidity were associated with earlier CR. For example, in female malignant melanoma, HRs and 95% confidence intervals were 0.47 (0.37-0.61) for high educational level, 1.40 (1.16-1.68) for living alone and 2.38 (1.53-3.70) for high comorbidity., Conclusion: The results may inform stratified risk assessment in decision of frequency, location and duration of post-cancer follow-up care., (© 2019 John Wiley & Sons Ltd.)

Objectives: To examine whether the quality of the patient-physician relationship, assessed by the general practitioner (GP) and the patient, associates with GPs' use of gut feeling (GF) in cancer diagnosis., Design: Cross-sectional questionnaire survey of cancer patients and their GPs., Setting: Danish primary care., Participants: Newly diagnosed cancer patients and their GPs. Patients completed a questionnaire and provided the name of the GP to whom they have presented their symptoms. The named GP subsequently received a questionnaire., Primary and Secondary Outcome Measures: GPs' use of GF in the diagnostic process for the particular patient. GPs who answered that they used their GF 'to a high degree' or 'to a very high degree' were categorised as 'used their GF to a great extent'. GPs who answered that they used their GF 'to some degree', 'to a limited degree' or 'not at all' were categorised as 'limited or no use of GF'., Results: GPs were less likely to use GF when they assessed relational aspects of the patient encounter as difficult compared with less difficult (OR=0.67; 95% CI 0.46 to 0.97). The physician-reported level of empathy was positively associated with use of GF (OR=2.60; 95% CI 1.60 to 4.22). The lower use of GF in difficult encounters was not modified by level of empathy., Conclusions: Experiencing relational aspects of patient encounter as difficult acted as a barrier for the use of GF in cancer diagnosis. Although physician-rated empathy increased use of GF, high empathy did not dissolve the low use of GF in difficult encounters. As diagnosis of cancer is a key challenge in primary care, it is important that GPs are aware that the sensitivity of cancer-related GF is compromised by a difficult patient-physician relationship., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Negative cancer beliefs have been associated with late stage at cancer diagnosis. High levels of negative cancer beliefs have been found among individuals with low socioeconomic position and ethnic minority women, but the impact of cancer experience on cancer beliefs is unexamined. The aim of this study was to examine whether cancer beliefs are associated with cancer experience. Methods: This was a cross-sectional population-based study. Telephone interviews of 2992 Danish residents (30+) were carried out using the Awareness and Beliefs about Cancer Measure (ABC). Respondents reported whether they or someone close had been diagnosed with cancer and whether they agreed/disagreed with three positively and three negatively framed cancer beliefs. Results: Respondents with someone close diagnosed was reference group. Compared with these, respondents with no cancer experience (RR adj =0.91, 95% CI=0.84-0.98) or who had had cancer themselves (RR adj =0.87, 0.77-0.98) were less likely to believe that cancer treatment is worse than the cancer itself, and respondents with no cancer experience were less likely to believe that a diagnosis of cancer is a death sentence (RR adj =0.83, 0.70-0.98), but more likely to report that they did not want to know if they had cancer (RR adj =1.31, 1.01-1.71). Conclusions: The results suggest that cancer beliefs are sensitive to cancer experience. This is an important addition to previous results focusing on the association between cancer beliefs and static factors such as socioeconomic position and ethnicity. Since cancer beliefs may determine health-related behaviour, it is important that negative cancer beliefs are addressed and possibly reframed in population-based interventions.

Background: Novel diagnostic triage and testing strategies to support early detection of cancer could improve clinical outcomes. Most apparently promising diagnostic tests ultimately fail because of inadequate performance in real-world, low prevalence populations such as primary care or general community populations. They should therefore be systematically evaluated before implementation to determine whether they lead to earlier detection, are cost-effective, and improve patient safety and quality of care, while minimising over-investigation and over-diagnosis., Methods: We performed a systematic scoping review of frameworks for the evaluation of tests and diagnostic approaches., Results: We identified 16 frameworks: none addressed the entire continuum from test development to impact on diagnosis and patient outcomes in the intended population, nor the way in which tests may be used for triage purposes as part of a wider diagnostic strategy. Informed by these findings, we developed a new framework, the 'CanTest Framework', which proposes five iterative research phases forming a clear translational pathway from new test development to health system implementation and evaluation., Conclusion: This framework is suitable for testing in low prevalence populations, where tests are often applied for triage testing and incorporated into a wider diagnostic strategy. It has relevance for a wide range of stakeholders including patients, policymakers, purchasers, healthcare providers and industry.

Objective: Healthcare systems increasingly make use of case managers to handle organisational complexity. In Danish cancer patient pathways, case managers handle the complexities of cancer diagnostics and treatment while adhering to pathway guidelines. This article explores how case managers handle their various responsibilities and focuses on the micro-politics of case management., Methods: An ethnographic study was carried out in three Danish cancer patient pathways. Interactions between patients and healthcare professionals were observed, including professionals with case management tasks. We interviewed 13 cancer diagnostic patients in their homes and 26 healthcare professionals during work hours, among other things about case management., Results: We found that the work of case managers differs between cancer patient pathways and settings but overall emphasises coordination of patient trajectories and being contact person. We argue that case managers, embodying the figure of the broker, handle their responsibilities by coordinating the following co-existing objects of care, each with different goals: the diseased body, the person, the organisation and the cancer patient pathway., Conclusion: We conclude that case managers, in addition to being a response to the complexity of healthcare services, impact the implementation of cancer patient pathways and influence cancer diagnostic activities., (© 2019 John Wiley & Sons Ltd.)

Background: This study aims to investigate the association between distance to health services and intervals in the cancer diagnostic pathway, and explore whether the diagnostic difficulty of the cancer influences this association., Method: A nationwide cohort study was conducted based on data from both questionnaires and registries. Danish cancer patients diagnosed in 2005-2016 and their general practitioner (GP) were included if enrolled in the Danish Cancer in Primary Care (CaP) cohort (n = 37,872). The CaP cohorts provided data on intervals assessed by patients and GPs. The Geographical Information System (GIS) was used to calculate travel distances from the residence of the patient to their GP surgery and to the hospital of diagnosis., Results: Longer travel distance to the hospital of diagnosis was associated with longer diagnostic interval. This association was strongest in the period before the implementation of Cancer Patient Pathways (CPP) in 2010. Patients with a cancer categorised as ´hard to diagnose´ contributed mostly to the association. Longer travel distance to the GP was associated with shorter patient interval and primary care interval for patients diagnosed with cancer types ´intermediate to diagnose´., Conclusion: Travel distance to cancer diagnostic health care services was associated with interval length in the diagnostic pathway. This association was less pronounced in the period after introducing CPPs and also strongly depending of the underlying cancer type and symptomatology., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Patients who rarely consult a GP in the 19-36 months before a cancer diagnosis have more advanced cancer at diagnosis and a worse prognosis. To ensure more timely diagnosis of cancer, the GP should suspect cancer as early as possible., Aim: To investigate the GP's suspicion of cancer according to the patient with cancer's usual consultation pattern in general practice., Design and Setting: A cross-sectional study based on survey data from general practice of 3985 Danish patients diagnosed with cancer from May 2010 to August 2010, and linked to national register data., Method: Using logistic regression analysis with restricted cubic splines, the odds ratio (OR) of the GP to suspect cancer as a function of the patient's number of face-to-face consultations with the GP in the 19-36 months before a cancer diagnosis was estimated., Results: GPs' cancer suspicion decreased with higher usual consultation frequency in general practice. A significant decreasing trend in ORs for cancer suspicion was seen across usual consultation categories overall ( P <0.001) and for each sex (males: P <0.05; females: P <0.05). GPs' cancer suspicion was lower in patients aged <55 years in both rare and frequent attenders compared with average attenders., Conclusion: GPs suspect cancer more often in rare attenders ≥55 years. GPs' cancer suspicion was lower in younger patients (<55 years), in both rare and frequent attenders. GPs should be aware of possible missed opportunities for cancer diagnosis in young attenders and use safety netting to reduce the risk of missing a cancer diagnosis., (© British Journal of General Practice 2019.)

Objective: We aimed to explore whether cancer patients urgently referred to a cancer patient pathway (CPP) (CPP referred) by a general practitioner report experiences of pre-diagnosis cancer care differently than patients not referred to a CPP (non-CPP referred)., Methods: Data were collected from cross-sectional questionnaire surveys among cancer patients and their GPs and linked to National registries. Poisson regression was used to generate adjusted prevalence ratios (PR) to compare reported experiences., Results: The study included 2,256 individuals. CPP referred patients reported more positive overall experiences of the pre-diagnosis phase (p < 0.001). Overall, CPP referred patients were 21% more likely than non-CPP referred patients to report a positive experience after adjustment for case-mix, comorbidity, disposable household income and educational level (PR = 1.21 [95% CI: 1.11-1.30]). The difference decreased to 14% when adjusted for Quality Deviations (PR = 1.14 [95% CI: 1.06-1.23]) and to 11% when adjusted for diagnostic interval (PR = 1.11 [95% CI: 1.02-1.20])., Conclusion: Our findings suggest that CPP referred cancer patients have better experiences of pre-diagnosis cancer care compared to non-CPP referred patients. A substantial part of the difference could be attributed to shorter diagnostic intervals and/or the absence of quality deviations among CPP patients, which reveals the potential for generally improving cancer patients' experiences by seamless and optimised diagnostic pathways., (© 2018 John Wiley & Sons Ltd.)

Introduction: Many countries have implemented cancer patient pathways (CPPs) for organ-specific cancers. However, due to high symptom diversity, it can be difficult for the General Practitioner (GP) to decide on the appropriate CPP., Objective: The aim of this study was to estimate the proportion of patients who were referred to a second CPP, were diagnosed with cancer or died within 6 months after receiving a negative result from clinical investigation through an initial CPP., Methods: We conducted a historical cohort study using routinely collected data with 6 months of follow-up. Data were collected from Danish registries., Results: We included 109998 study subjects: 0.6% received a cancer diagnosis, 2.3% died and 6.1% were referred to a second CPP within 6 months. A total of 48.9% of the re-referrals after a first CPP in the gastrointestinal (GI) area were also referred to a second CPP in the GI area. Re-referral to a second CPP corresponded to a positive predictive value (PPV) of 4.4% to be diagnosed with cancer., Conclusion: A total of 6% of patients who received a negative result after investigation in an organ-specific CPP were re-referred within 6 months to a new organ-specific CPP; many of these were in the same anatomical area as the first CPP. The PPV of 4.4% to be diagnosed with cancer indicates that some cancers may be missed in the diagnostic investigation through the first CPP. This calls for reconsideration of how CPPs may best support the primary cancer diagnosis.

Objectives: Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking.This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries., Design: Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making., Setting: A primary care study; 25 participating centres in 20 European countries., Participants: 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%., Outcome Measures: The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons., Results: Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses., Conclusions: Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Over recent years there has been a growth in cancer early diagnosis (ED) research, which requires valid measurement of routes to diagnosis and diagnostic intervals. The Aarhus Statement, published in 2012, provided methodological guidance to generate valid data on these key pre-diagnostic measures. However, there is still a wide variety of measuring instruments of varying quality in published research. In this paper we test comprehension of self-completion ED questionnaire items, based on Aarhus Statement guidance, and seek input from patients, GPs and ED researchers to refine these questions., Methods: We used personal interviews and consensus approaches to generate draft ED questionnaire items, then a combination of focus groups and telephone interviews to test comprehension and obtain feedback. A framework analysis approach was used, to identify themes and potential refinements to the items., Results: We found that many of the questionnaire items still prompted uncertainty in respondents, in both routes to diagnosis and diagnostic interval measurement. Uncertainty was greatest in the context of multiple or vague symptoms, and potentially ambiguous time-points (such as 'date of referral')., Conclusions: There are limits on the validity of self-completion questionnaire responses, and refinements to the wording of questions may not be able to completely overcome these limitations. It's important that ED researchers use the best identifiable measuring instruments, but accommodate inevitable uncertainty in the interpretation of their results. Every effort should be made to increase clarity of questions and responses, and use of two or more data sources should be considered.

Objectives: Early diagnosis of childhood cancer is critical. Nevertheless, little is known about the potential role of inequality. This study aims to describe the use of primary care 2 years before a childhood cancer diagnosis and to investigate whether socioeconomic factors influence the use of consultations and diagnostic tests in primary care., Design: A national population-based matched cohort study., Setting and Participants: This study uses observational data from four Danish nationwide registers. All children aged 0-15 diagnosed with cancer during 2008-2015 were included (n=1386). Each case was matched based on gender and age with 10 references (n=13 860)., Primary and Secondary Outcome Measures: The primary outcome was additional rates for consultations and for invoiced diagnostic tests for children with cancer according to parental socioeconomic factors. Furthermore, we estimated the association between socioeconomic factors and frequent use of consultations, defined as at least four consultations, and the odds of receiving a diagnostic test within 3 months of diagnosis., Results: Children with cancer from families with high income had 1.46 (95% CI 1.23 to 1.69) additional consultations 3 months before diagnosis, whereas children from families with low income had 1.85 (95% CI 1.60 to 2.11) additional consultations. The highest odds of frequent use of consultations was observed among children from low-income families (OR: 1.94, 95% CI 1.24 to 3.03). A higher odds of receiving an invoiced diagnostic test was seen for children from families with mid-educational level (OR: 1.46, 95% CI 1.09 to 1.95)., Conclusion: We found a socioeconomic gradient in the use of general practice before a childhood cancer diagnosis. This suggests that social inequalities exist in the pattern of healthcare utilisation in general practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cancer patients who usually consult the general practitioner (GP) rarely are generally diagnosed with more advanced stages of cancer. This subgroup of cancer patients may thus postpone relevant healthcare seeking., Aim: We aimed to investigate the rates of daytime face-to-face consultations in general practice before a cancer diagnosis in patients with different categories of 'usual' consultation frequency., Material and Methods: We conducted a population-based comparative study using register data on all 123,934 first-time cancer patients aged 50-90 years who were diagnosed in 2009-2013 in Denmark. Usual consultation rates were based on number of consultations from 19 to 36 months before cancer diagnosis. We predicted the marginal monthly consultation rates for up to 18 months before diagnosis. These were based on the estimated (mean) rates of consultations with corresponding 95% confidence intervals (CIs), which were calculated by negative binomial regression analysis with robust variance estimation., Results: Patients with cancer began to increase their consultation frequency four to six months before their cancer diagnosis. The average monthly consultation rates varied slightly across usual consultation groups; rates were lowest among male 'frequent' consulters (0.28 (95% CI: 0.27;0.29)) and highest among female 'frequent' consulters (0.35 (95% CI: 0.34;0.37)). The additional number of consultations was 1-2 for all combinations of usual consultation frequency, sex, and cancer type (except for female breast cancer and 'average' consulters with lung or prostate cancer)., Conclusion: Patients with cancer begin to increase their consultation frequency in general practice before a cancer diagnosis independently of their usual consultation frequency., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: 'Diagnostic Centres' has been established to provide a diagnostic pathway for patients with non-specific, serious symptoms that could be cancer. As little is known about the prognosis, we aimed to 1) analyse mortality of patients examined at the diagnostic centre, stratified on diagnostic outcome (cancer, serious-non-malignant disease, or other/no diagnosis), and 2) compare mortality for cancer patients examined at the diagnostic centre with cancer patients diagnosed through other routes., Method: Retrospective cohort study including 938 patients examined at the Diagnostic Centre, Silkeborg Regional Hospital, Denmark, during 2012-2014. Cancer patients examined at the diagnostic centre were matched (1:10) to a reference group of cancer patients diagnosed through other routes. Information on diagnosis, death, comorbidity and socioeconomic factors was obtained by linkage to national Danish registers. Mortality was assessed by Kaplan Meier mortality survival analysis and hazard ratios of death were estimated using Cox proportional regression analysis while adjusting for confounders., Results: The 1-year cumulative mortality was 28% in cancer patients examined at the diagnostic centre. The hazard ratio of death was seven times increased in cancer patients compared to patients with other/no diagnosis. The hazard ratio of death was 0.91 (95% CI: 0.68; 1.22) in cancer patients examined at the diagnostic centre compared to cancer patients diagnosed through other routes., Discussion: The mortality among cancer patients examined at the diagnostic centre was comparable to cancer patients diagnosed through other routes. The results indicate that cancer patients with non-specific serious symptoms do not have a worse prognosis than other cancer patients., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: It is unclear to what extent primary care practitioners (PCPs) should retain responsibility for follow-up to ensure that patients are monitored until their symptoms or signs are explained., Aim: To explore the extent to which PCPs retain responsibility for diagnostic follow-up actions across 11 international jurisdictions., Design and Setting: A secondary analysis of survey data from the International Cancer Benchmarking Partnership., Method: The authors counted the proportion of 2879 PCPs who retained responsibility for each area of follow-up (appointments, test results, and non-attenders). Proportions were weighted by the sample size of each jurisdiction. Pooled estimates were obtained using a random-effects model, and UK estimates were compared with non-UK ones. Free-text responses were analysed to contextualise quantitative findings using a modified grounded theory approach., Results: PCPs varied in their retention of responsibility for follow-up from 19% to 97% across jurisdictions and area of follow-up. Test reconciliation was inadequate in most jurisdictions. Significantly fewer UK PCPs retained responsibility for test result communication (73% versus 85%, P = 0.04) and non-attender follow-up (78% versus 93%, P <0.01) compared with non-UK PCPs. PCPs have developed bespoke, inconsistent solutions to follow-up. In cases of greatest concern, 'double safety netting' is described, where both patient and PCP retain responsibility., Conclusion: The degree to which PCPs retain responsibility for follow-up is dependent on their level of concern about the patient and their primary care system's properties. Integrated systems to support follow-up are at present underutilised, and research into their development, uptake, and effectiveness seems warranted., (© British Journal of General Practice 2018.)

Background: Understanding what influences people to seek help can inform interventions to promote earlier diagnosis of cancer, and ultimately better cancer survival. We aimed to examine relationships between negative cancer beliefs, recognition of cancer symptoms and how long people think they would take to go to the doctor with possible cancer symptoms (anticipated patient intervals)., Methods: Telephone interviews of 20,814 individuals (50+) in the United Kingdom, Australia, Canada, Denmark, Norway and Sweden were carried out using the Awareness and Beliefs about Cancer Measure (ABC). ABC included items on cancer beliefs, recognition of cancer symptoms and anticipated time to help-seeking for cough and rectal bleeding. The anticipated time to help-seeking was dichotomised as over one month for persistent cough and over one week for rectal bleeding., Results: Not recognising persistent cough/hoarseness and unexplained bleeding as cancer symptoms increased the likelihood of a longer anticipated patient interval for persistent cough (OR = 1.66; 95%CI = 1.47-1.87) and rectal bleeding (OR = 1.90; 95%CI = 1.58-2.30), respectively. Endorsing four or more out of six negative beliefs about cancer increased the likelihood of longer anticipated patient intervals for persistent cough and rectal bleeding (OR = 2.18; 95%CI = 1.71-2.78 and OR = 1.97; 95%CI = 1.51-2.57). Many negative beliefs about cancer moderated the relationship between not recognising unexplained bleeding as a cancer symptom and longer anticipated patient interval for rectal bleeding (p = 0.005)., Conclusions: Intervention studies should address both negative beliefs about cancer and knowledge of symptoms to optimise the effect.

Background: Asking patients with palliative care needs about their end-of-life (EoL) preferences is widely acknowledged as an important aspect of EoL care. However, the issue of how to ask patients these questions has not been fully explored. Most prior studies in this area do not differentiate between patients' pragmatic preferences and ideal preferences, and between preferences concerning place of care (PoC) and place of death (PoD)., Aim: The aim of this study was to examine possible differences between pragmatic and ideal preferences of terminally ill patients, as well as differences between asking patients about preferences concerning PoC and PoD., Methods: Structured interviews were performed with terminally ill cancer patients at inclusion and a follow-up questionnaire was completed 1 month later. Answers were compared using kappa (k) statistics and Pearson's c 2 -test., Results: Among 96 cancer patients, agreement between pragmatic and ideal preferences was statistically significantly different (p=<0.001). Agreement between preferences for PoC and PoD was high (k:0.76-0.85)., Conclusion: Differences exist between pragmatic and ideal EoL preferences, whereas preferences for PoC and PoD were found to be similar. These findings highlight the importance of the phrasing of questions when uncovering patients' preferences for EoL care.

Background: Previous studies of associations between home visits by general practitioners and end-of-life care for cancer patients have been subject to confounding., Aim: To analyse associations between general practitioners' propensity to pay home visits and the likelihood of hospitalisation and dying out of hospital among their cancer patients., Design: A national register cohort study with an ecological exposure. Standardised incidence rates of general practitioner home visits were calculated as a measure for propensity. Practices were grouped into propensity quartiles. Associations between propensity groups and end-of-life outcomes for cancer patients aged 40 or above were calculated., Setting/participants: Danish general practitioners and citizens aged 40 or above were included from 2003 to 2012., Results: We included 2670 practices with 2,518,091 listed patients (18,364,679 person-years); of whom 116,677 died from cancer. General practitioners were grouped into quartiles based on the general practitioners' propensity to pay home visits, which varied 6.6-fold between quartiles. Cancer patients in Group 4 (highest propensity) were less hospitalised than patients in Group 1 (lowest propensity): odds ratio: 1.13 (95% confidence interval: 1.08; 1.17) for ⩽3 bed-days and odds ratio: 0.95 (0.91-0.99) for ⩾20 bed-days. Group 4 patients were more likely to die out of hospital (odds ratio: 1.20 (1.16; 1.24)) than Group 1 patients., Conclusion: We found a dose-response-like association between general practitioners' higher propensity to pay home visit and their patients' likelihood of less end-of-life hospitalisation and more often dying out of hospital.

Cancer survival rates are lower in Denmark than in comparable European countries. This may partly be attributable to subgroups of cancer patients who seek medical attention at late disease stages. It is unknown if differences in usual (i.e. customary) consultation frequency in general practice are associated with cancer prognosis. We aimed to estimate the cancer prognosis of cancer patients stratified by their usual consultation frequency in general practice. We performed a population-based cohort study including 123,943 incident cancer patients aged 50 to 89 years diagnosed in Denmark in 2009 to 2013. We estimated associations between the patient's usual general practitioner (GP) consultation frequency 19 to 36 months before the cancer diagnosis and all-cause mortality by using hazard ratios (HR), estimated by Cox proportional hazards regression. We also estimated the associations between the patient's usual GP consultation frequency and tumour stage, by using logistic regression estimates of odds ratios (ORs). Patients who usually did not see their GP (non-consulters) had higher all-cause mortality [HR = 1.39 (95% CI: 1.33-1.44)] compared to patients who usually saw their GP three to five times during an 18 months period (average consulters). Non-consulters had higher odds of having distant tumour stage [OR = 1.46 (95% CI: 1.38-1.57)] than average consulters. Similar, yet less strong, patterns were seen among patients with low usual GP consultation frequency, yet not statistically significant for all cancer types. In conclusion, the association between usual GP non-consultation and cancer prognosis is a combination of at least two things: a mechanism through more advanced tumour stage and other independent factors., (© 2017 UICC.)

Background: Danish cancer patients have lower survival rates than patients in many other western countries. Half of the patients present with non-alarm symptoms and thus have a long diagnostic pathway. Consequently, an urgent referral pathway for patients with non-specific serious symptoms was implemented throughout Denmark in 2011-2012. As part of the diagnostic workup, a panel of blood tests are performed for all patients referred by their general practitioner (GP) to the urgent referral pathway. In this study, we analysed the probability of being diagnosed with cancer in GP-referred patients with abnormal blood test results., Method: We performed a cohort study that included all patients aged 18 years or older referred by their GP to Silkeborg Regional Hospital for analysis of a panel of blood tests. All patients were followed for 3 months for a cancer diagnosis in the Danish Cancer Registry. The likelihood ratio and post-test probability of subsequently finding cancer were calculated in relation to abnormal blood test results., Results: Among the 1499 patients included in the study, 12.2% were subsequently diagnosed with cancer. The probability of cancer increased with the number of abnormal blood tests. Patients with specific combinations of two abnormal blood tests had a 23-62% probability of cancer. Only a few single abnormal blood tests were linked with a high post-test probability of cancer, and most abnormalities were not specific to cancer., Conclusions: A number of specific abnormal blood tests and combinations of abnormal blood tests markedly increased the probability of cancer being diagnosed. Still, abnormal blood test results should be interpreted cautiously as most are non-specific to cancer. Thus, results from the blood test panel may strengthen the suspicion of cancer, but blood tests cannot be used as a stand-alone tool to rule out cancer.

Objective: Severe grief symptoms in family caregivers during end-of-life cancer trajectories are associated with complicated grief and depression after the loss. Nevertheless, severe grief symptoms during end-of-life caregiving in caregivers to cancer patients have been scarcely studied. We aimed to explore associations between severe preloss grief symptoms in caregivers and modifiable factors such as depressive symptoms, caregiver burden, preparedness for death, and end-of-life communication., Methods: We conducted a population-based prospective study of caregivers to 9512 patients registered with drug reimbursement due to terminal illness, and 3635 caregivers responded. Of these, 2865 caregivers to cancer patients completed a preloss grief scale (Prolonged Grief 13, preloss version). Associations with factors measured during end-of-life caregiving were analyzed using logistic regression., Results: Severe preloss grief symptoms were reported by 432 caregivers (15.2%). These symptoms were associated with depressive symptoms (adjusted odds ratio [OR] = 12.4; 95% CI, 9.5-16.3), high caregiver burden (adjusted OR = 8.3; 95% CI, 6.3-11.1), low preparedness for death (adjusted OR = 3.3; 95% CI, 2.5-4.4), low level of communication about dying (adjusted OR = 3.2; 95% CI, 2.2-4.4), and "too much" prognostic information (adjusted OR = 2.8; 95%, 1.7-4.6)., Conclusions: Severe preloss grief symptoms were significantly associated with distress, low preparedness, and little communication during caregiving. Thus, severe preloss grief symptoms may be a key indicator for complications in caregivers of cancer patients in an end-of-life trajectory. Targeted interventions are needed to support family caregivers with severe preloss grief symptoms. Development of preloss grief assessment tools and interventions should be a priority target in future research., (Copyright © 2017 John Wiley & Sons, Ltd.)

Background: Little is known about the clinical characteristics of patients referred to a diagnostic centre through the Danish urgent referral pathway for non-specific serious symptoms. We aimed at estimating the distribution of serious disease and the diagnostic value of clinical characteristics for the diagnosis of cancer and serious non-malignant disease in these patients., Method: A cohort study of 938 patients referred by their GP to the diagnostic centre at Silkeborg Regional Hospital. All patients were followed up for three months in national registries. The likelihood ratio (LR) of cancer or serious non-malignant disease were calculated in relation to clinical characteristics., Results: A total of 327 (34.9%) patients were diagnosed with new serious disease within three months: 118 patients (12.6%) with malignant disease and 209 patients (22.3%) with non-malignant disease. Most patients presented general symptoms. The highest LR of cancer was found for abdominal mass, high lactate dehydrogenase or abnormal findings in the diagnostic imaging. The highest LR of non-malignant disease was found for swollen joints or abnormal auscultation of lung or chest., Conclusions: Patients referred by their GP to the diagnostic centre have high risk of serious disease. A multidisciplinary diagnostic approach is needed to embrace the diagnostic spectrum., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Cancer Patient Pathways (CPPs) were introduced in 2000-2015 in several European countries, including Denmark, to reduce the time to diagnosis and treatment initiation and ultimately improve patient survival. Yet, the prognostic consequences of implementing CPPs remain unknown for symptomatic cancer patients diagnosed through primary care. We aimed to compare survival and mortality among symptomatic patients diagnosed through a primary care route before, during and after the CPP implementation in Denmark., Methods: Based on data from the Danish Cancer in Primary Care (CaP) Cohort, we compared one- and three-year standardised relative survival (RS) and excess hazard ratios (EHRs) before, during and after CPP implementation for seven types of cancer and all combined (n = 7725) by using life-table estimation and Poisson regression. RS estimates were standardised according to the International Cancer Survival Standard (ICSS) weights. In addition, we compared RS and EHRs for CPP and non-CPP referred patients to consider potential issues of confounding by indication., Results: In total, 7725 cases were analysed: 1202 before, 4187 during and 2336 after CPP implementation. For all cancers combined, the RS 3years rose from 45% (95% confidence interval (CI): 42;47) before to 54% (95% CI: 52;56) after CPP implementation. The excess mortality was higher before than after CPP implementation (EHR 3years before vs. after CPP = 1.35 (95% CI: 1.21;1.51)). When comparing CPP against non-CPP referred patients, we found no statistically significant differences in RS, but we found lower excess mortality among the CPP referred (EHR 1year CPP vs. non-CPP = 0.86 (95% CI: 0.73;1.01))., Conclusion: We found higher relative survival and lower mortality among symptomatic cancer patients diagnosed through primary care after the implementation of CPPs in Denmark. The observed changes in cancer prognosis could be the intended consequences of finding and treating cancer at an early stage, but they may also reflect lead-time bias and selection bias. The finding of a lower excess mortality among CPP referred compared to non-CPP referred patients indicates that CPPs may have improved the cancer prognosis independently.

Background: Implementation of standardised cancer patient pathways (CPPs) has provided faster diagnosis of cancer. Cancer survival has improved during the same time period. Concern has been raised that the faster diagnosis may have introduced lead-time bias by elongating the period from diagnosis to death., Aim: We aimed to analyse the possible effect of lead time on survival due to expedited cancer diagnosis after the implementation of national CPPs among incident cancer patients diagnosed through Danish primary care., Material and Methods: We used actual observed differences in diagnostic intervals to estimate the lead-time effect. We used data from sub-cohorts from the Danish Cancer in Primary Care (CaP) cohort of first-time cancer patients: before and after CPP implementation. To calculate differences in absolute survival, we estimated the survival function after advancing the date of diagnosis in the before cohort to an earlier point in time and hereby adjusting for lead time for nine cancer types and all combined by using Kaplan-Meier analysis., Results: Advancing the date of diagnosis implied that the absolute one-year survival increased from 68.5% to 69.4%. This accounted for 13% of the observed differences in absolute one-year survival from before to after CPPs., Conclusion: The lead time caused by shorter diagnostic intervals after implementation of Cancer Patient Pathways seems to explain less than 15% of the observed changes in the one-year survival estimates for cancer patients in Denmark., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: The International Cancer Benchmarking Partnership aims to study international differences in cancer survival and the possible causes. Participating countries are Australia, Canada, Norway, Sweden, Denmark and the UK and a particular focus area is differences in awareness and beliefs about cancer. In this connection, the Awareness and Beliefs about Cancer (ABC) measure has been translated into multiple languages. The aim of this study is to appraise the translation process and measurement properties of the Danish version of the ABC measure., Methods: The translation process included forward and backward translations and a pilot-test. Data quality was assessed using survey data from 3000 Danish respondents and content validity indexes were calculated based on judgments from ten academic researchers. Construct validity was determined by a confirmative factor analysis (CFA) and exploratory factor analyses (EFA) using survey data and a known group comparison analysis including 56 persons. Test-retest reliability was assessed based on responses from 123 person whom completed the interview twice with an interval of 2-3 weeks., Results: The translation process resulted in a Danish ABC measure conceptually equivalent to the English ABC measure. Data quality was acceptable in relation to non-response to individual items which was maximum 0.3%, but the percentage of respondents answering 'don't know' was above 3% for 16 out of 48 items. Content validity indexes showed that items adequately reflected and represented the constructs to be measured (item content validity indexes: 0.9-1.0; construct content validity indexes: 0.8-1.0). The hypothesised factor structure could not be replicated by a CFA, but EFA on each individual subscale showed that six out of seven subscales were unidimensional. The ABC measure discriminated well between non-medical academics and medical academics, but had some difficulties in discriminating between educational groups. Test-retest reliability was moderate to substantial for most items., Conclusions: The Danish ABC measure is a useful measurement that is accepted and understood by the target group and with accepted measurement criteria for content validity and test-retest reliability. Future studies may further explore the factorial structure of the ABC measure and should focus on improving the response categories.

Background: Detection of cancer in general practice is challenging because symptoms are diverse. Even so-called alarm symptoms have low positive predictive values of cancer. Nevertheless, appropriate referral is crucial. As 85% of cancer patients initiate their cancer diagnostic pathway in general practice, a Continuing Medical Education meeting (CME-M) in early cancer diagnosis was launched in Denmark in 2012. We aimed to investigate the effect of the CME-M on the primary care interval, patient contacts with general practice and use of urgent cancer referrals., Methods: A before-after study was conducted in the Central Denmark Region included 396 general practices, which were assigned to one of eight geographical clusters. Practices were invited to participate in the CME-M with three-week intervals between clusters. Based on register data, we calculated urgent referral rates and patient contacts with general practice before referral. Information about primary care intervals was collected by requesting general practitioners to complete a one-page form for each urgent referral during an 8-month period around the time of the CME-Ms. CME-M practices were compared with non-participating reference practices by analysing before-after differences., Results: Forty percent of all practices participated in the CME-M. There was a statistically significant reduction in the number of total contacts with general practice from urgently referred patients in the month preceding the referral and an increase in the proportion of patients who waited 14 days or more in general practice from the reported date of symptom presentation to the referral date from before to after the CME-M in the CME-M group compared to the reference group., Conclusions: We found a reduced number of total patient contacts with general practice within the month preceding an urgent referral and an increase in the reported primary care intervals of urgently referred patients in the CME-M group. The trend towards higher urgent referral rates and longer primary care intervals may suggest raised awareness of unspecific cancer symptoms, which could cause the GP to register an earlier date of first symptom presentation. The standardised CME-M may contribute to optimising the timing and the use of urgent cancer referral., Trial Registration: NCT02069470 on ClinicalTrials.gov. Retrospectively registered, 1/29/2014.

Background: Late effects after cancer diagnosis and treatment are common, but only few studies have examined the role of social factors in developing these late effects. The aim of this study was to examine the association between educational level and physical function and pain among cancer survivors two years after diagnosis., Material and Methods: The study population consisted of adult Danish patients with a first-time cancer diagnosis who were sent a questionnaire in 2010 and followed up in 2012. In total, 4346 returned the first questionnaire shortly after diagnosis and 2568 returned the follow-up questionnaire. After exclusion of 177 due to missing information, we included 2391 cancer survivors in the analyses. Physical function and pain were measured using the EORTC QLQ-C30. Linear regression analyses were conducted separately for men and women, and adjusted for demographic and clinical characteristics. Additionally, analyses were stratified on comorbidity., Results: Differences in mean scores according to educational level were small. Physical function was better in women with medium (2.8; 95% CI 0.1;5.4) and higher education (3.4; 95% CI 0.9;5.9) compared to women with short education. In contrast, men with medium education reported lower physical function (-2.9; 95% CI -5.7;-0.1) than men with short education. Compared to women with short education, we found lower pain scores among women with medium (-5.0; 95% CI -8.7;-1.4) and higher education (-3.4; 95% CI -6.7;0.0). Similarly, men with higher education experienced lower pain score (-3.4; 95% CI -6.9;0.1) than men with short education. The role of educational level differed between those with and without comorbidity., Conclusion: Educational level is slightly associated with physical function and pain among cancer survivors. However, mean differences in this study were small and below what is considered clinically relevant.

Introduction: Standardised cancer patient pathways (CPPs) were implemented in Denmark in 2008 to reduce the waiting time during the diagnostic process and hereby improve patient satisfaction. The aim of this study was to investigate whether patient-reported dissatisfaction with long waiting times has changed from "before" to "after" the implementation of CPPs., Methods: We conducted a comparative cohort study by comparing the patient-reported dissatisfaction with long waiting time before (2004/2005) and after (2010) CPP implementation. Logistic regression was used to estimate the odds ratios (ORs) for patient-reported dissatisfaction after CPP implementation compared with before., Results: Fewer patients reported dissatisfaction with long waiting time from the time of referral by their general practitioner (GP) to the first consultation at the hospital across the time of CPP implementation (p < 0.001) (adjusted OR = 0.6 (95% confidence interval (CI): 0.5-0.8)). More patients reported dissatisfaction with long waiting time to get an appointment with their GP across the time of CPP implementation (p < 0.001) (adjusted OR = 3.7 (95% CI: 2.5-5.3))., Conclusion: CPP implementation in Denmark was associated with a reduced level of patient-reported dissatisfaction with long waiting time from the time of referral to the first consultation at the hospital. This indicates that the CPP objective of increasing patient satisfaction may have been achieved. Nevertheless, more patients reported dissatisfaction with long waiting time to get an appointment with their GP., Funding: none., Trial Registration: not relevant.

Objective: To examine provincial and regional differences in FPs' direct access to cancer diagnostic investigations and advice from other specialists regarding investigations and referrals, and to explore FPs' perceptions about wait times for diagnostic investigations and receipt of results., Design: A cross-sectional, online survey., Setting: British Columbia, Manitoba, and Ontario., Participants: A sample of FPs from participating provinces., Main Outcome Measures: Direct FP access to various diagnostic investigations and advice from other specialists regarding investigations and referrals; FPs' perceptions about wait times for diagnostic investigations ordered directly; and FPs' perceptions about wait times for results., Results: A total of 1054 surveys were completed by FPs from British Columbia (n = 229), Manitoba (n = 228), and Ontario (n = 597). Distance from a cancer centre was not significantly associated with direct access to or wait times for diagnostic investigations for most of the investigations studied; however, provincial differences were observed. Family physicians in Manitoba and British Columbia were 30% to 45% less likely to report having direct access to endoscopy and some imaging investigations compared with FPs in Ontario. Family physicians in Manitoba and British Columbia were also at increased odds of waiting longer than 12 weeks for endoscopy investigations and longer than 4 weeks for imaging investigations compared with FPs in Ontario. Most FPs reported wait times of less than 2 weeks for imaging results; however, the proportion of FPs who waited longer than 2 weeks for colonoscopy results ranged from 15% in Ontario to 96% in British Columbia., Conclusion: Given the disparities observed among provinces, there is an opportunity for provinces to learn from one another to improve direct access to and shorten wait times for diagnostic investigations. This in turn has the potential to shorten the primary care interval for cancer diagnostic assessment., (Copyright© the College of Family Physicians of Canada.)

Background: Continuing medical education (CME) in earlier cancer diagnosis was launched in Denmark in 2012 as part of the Danish National Cancer Plan. The CME programme was introduced to improve the recognition among general practitioners (GPs) of symptoms suggestive of cancer and improve the selection of patients requiring urgent investigation. This study aims to explore the effect of CME on GP knowledge about cancer diagnosis, attitude towards own role in cancer detection, self-assessed readiness to investigate and cancer risk assessment of urgently referred patients., Methods: We conducted a before-after study in the Central Denmark Region including 831 GPs assigned to one of eight geographical clusters. All GPs were invited to participate in the CME at three-week intervals between clusters. A questionnaire focusing on knowledge, attitude and clinical vignettes was sent to each GP one month before and seven months after the CME. The GPs were also asked to assess the risk of cancer in patients urgently referred to a fast-track cancer pathway during an eight-month period. CME-participating GPs were compared with reference (non-participating) GPs by analysing before-after differences., Results: One quarter of all GPs participated in the CME. 202 GPs (24.3 %) completed both the baseline and the follow-up questionnaires. 532 GPs (64.0 %) assessed the risk of cancer before the CME and 524 GPs (63.1 %) assessed the risk of cancer after the CME in urgently referred consecutive patients. Compared to the reference group, CME-participating GPs statistically significantly improved their understanding of a rational probability of diagnosing cancer among patients urgently referred for suspected cancer, increased their knowledge of cancer likelihood in a 50-year-old referred patient and lowered the assessed risk of cancer in urgently referred patients., Conclusions: The standardised CME lowered the GP-assessed cancer risk of urgently referred patients, whereas the effect on knowledge about cancer diagnosis and attitude towards own role in cancer detection was limited. No effect was found on the GPs' readiness to investigate. CME may be effective for optimising the interpretation of cancer symptoms and thereby improve the selection of patients for urgent cancer referral., Trial Registration: NCT02069470 on ClinicalTrials.gov. Retrospectively registered, 1/29/2014.

Background: General practice plays an important role in the cancer care pathway. Patient dissatisfaction with the diagnostic process may be expressed by changing to another general practice., Aim: To compare the frequency of change of practice (COP) in patients with cancer (n = 150 216) with a matched cancer-free control cohort (n = 1 502 114) and to analyse associations with cancer type and patient characteristics., Design and Setting: A population-based matched cohort study using historical and prospectively collected data from Danish nationwide registers., Method: COP was defined as a change of practice list, unrelated to change of address or reorganisation of the practice. Data were analysed monthly in the year before and after a cancer diagnosis., Results: More patients with cancer than controls changed general practice (4.1% versus 2.6%) from 7 months before and until 12 months after diagnosis. The COP rate varied by cancer type (rectal cancer served as reference). Before the diagnosis, COP was most often seen among patients with ovarian cancer (risk ratio [RR] 1.51, 95% confidence interval [CI] = 1.10 to 2.08) and multiple myeloma (RR 1.89, 95% CI = 1.34 to 2.67). After the diagnosis, COP was most frequent among patients with brain cancer (RR 1.38, 95% CI = 1.05 to 1.82) and ovarian cancer (RR 1.51, 95% CI = 1.21 to 1.88)., Conclusion: Patients with cancer changed general practice more frequently than the cancer-free controls. COP variations between cancer types may be attributed to lack of diagnostic timeliness due to clinical complexity of the diagnosis and the role of the GP in the diagnostic process., (© British Journal of General Practice 2016.)